Special September 11th Issue of The Lancet

September 3, 2011

As we mark the 10th anniversary of the 9/11 attacks, a recent issue of The Lancet [Volume 378, Issue No. 9794, Pages 849-960 (3 September, 2011)] devoted a substantial portion of its Editorial, Comment, Viewpoint, and Articles sections to explore some of the research, review, and opinion pieces on the short-term and long-term physical, mental, and public health consequences of the September 11, 2001, terrorist attacks in New York City. More specifically, the journal addresses important issues concerning: mortality of rescue and recovery workers as well as non-rescue and non-recovery participants; persistent physical and mental health effects among rescue and recovery workers; and cancer outcomes among firefighters who responded.

Below are the abstracts for the three issues mentioned above. For the full text of the article, or more information about this special edition, visit The Lancet website at http://www.thelancet.com .

• Mortality among survivors of the Sept 11, 2001, World Trade Center disaster: results from the World Trade Center Health Registry cohort.
  Hannah T Jordan, Robert M Brackbill, James E Cone, Indira Debchoudhury, Mark R Farfel, Carolyn M Greene, James L Hadler, Joseph Kennedy, Jiehui Li, Jonathan Liff , Leslie Stayner, Steven D Stellman. Lancet September 3, 2011, Vol. 378, No. 9794, pp. 879–887.
  
  In this observational cohort study, deaths occurring in 2003–09 in WTC Health Registry participants residing in New York City were identified through linkage to New York City vital records and the National Death Index. The study identified 156 deaths in 13,337 rescue and recovery workers and 634 deaths in 28,593 non-rescue and non-recovery participants. All-cause SMRs were significantly lower than that expected for rescue and recovery participants (SMR 0.45, 95% CI 0.38–0.53) and non-rescue and non-recovery participants (0.61, 0.56–0.66). No significantly increased SMRs for diseases of the respiratory system or heart, or for haematological malignancies were found. In non-rescue and non-recovery participants, both intermediate and high levels of WTC-related exposure were significantly associated with mortality when compared with low exposure (adjusted hazard ratio 1·22, 95% CI1.01–1.48, for intermediate exposure and 1.56, 1.15–2.12, for high exposure). High levels of exposure in non-rescue and non-recovery individuals, when compared with low exposed non-rescue and non-recovery individuals, were associated with heart disease-related mortality (adjusted hazard ratio 2·06, 1.10–3.86). In rescue and recovery participants, level of WTC-related exposure was not significantly associated with all-cause mortality (adjusted hazard ratio 1·25, 95% CI 0·56–2·78, for high exposure and 1.03, 0.52–2.06, for intermediate exposure when compared with low exposure). This exploratory study of mortality in a well-defined cohort of 9/11 survivors provides a baseline for continued surveillance. Additional follow-up is needed to establish whether these associations persist and whether a similar association over time will occur in rescue and recovery participants.
  
  
• Persistence of multiple illnesses in World Trade Center rescue and recovery workers: a cohort study.
  Juan P Wisnivesky, Susan L Teitelbaum, Andrew C Todd, Paolo Boffff etta, Michael Crane, Laura Crowley, Rafael E de la Hoz, Cornelia Dellenbaugh, Denise Harrison, Robin Herbert, Hyun Kim, Yunho Jeon, Julia Kaplan, Craig Katz, Stephen Levin, Ben Luft, Steven Markowitz, Jacqueline M Moline, Fatih Ozbay, Robert H Pietrzak, Moshe Shapiro, Vansh Sharma, Gwen Skloot, Steven Southwick, Lori A Stevenson, Iris Udasin, Sylvan Wallenstein, Philip J Landrigan. Lancet September 3, 2011, Vol. 378, No. 9794, pp. 888–897.
  
  This paper reports incidence and prevalence rates of physical and mental health disorders during the 9 years since the attacks, examines their associations with occupational exposures, and quantifies physical and mental health comorbidities. In this longitudinal study of a large cohort of WTC rescue and recovery workers, data were gathered from 27,449 participants in the WTC Screening, Monitoring, and Treatment Program. The study population included police officers, firefighters, construction workers, and municipal workers. The cumulative and annual incidence of physical disorders (asthma, sinusitis, and gastro-oesophageal reflux disease), mental health disorders (depression, post-traumatic stress disorder [PTSD], and panic disorder), and spirometric abnormalities were estimated. Incidence rates were assessed also by level of exposure (days worked at the WTC site and exposure to the dust cloud). Findings 9-year cumulative incidence of asthma was 27·6% (number at risk: 7027), sinusitis 42·3% (5870), and gastrooesophageal reflux disease 39·3% (5650). In police officers, cumulative incidence of depression was 7·0% (number at risk: 3648), PTSD 9·3% (3761), and panic disorder 8·4% (3780). In other rescue and recovery workers, cumulative incidence of depression was 27·5% (number at risk: 4200), PTSD 31·9% (4342), and panic disorder 21·2% (4953). 9-year cumulative incidence for spirometric abnormalities was 41·8% (number at risk: 5769); three-quarters of these abnormalities were low forced vital capacity. Incidence of most disorders was highest in workers with greatest WTC exposure. Extensive comorbidity was reported within and between physical and mental health disorders. 9 years after the 9/11 WTC attacks, rescue and recovery workers continue to have a substantial burden of physical and mental health problems. These findings emphasize the need for continued monitoring and treatment of the WTC rescue and recovery population.
  
  
• Early assessment of cancer outcomes in New York City firefighters after the 9/11 attacks: an observational cohort study.
  Rachel Zeig-Owens, Mayris P Webber, Charles B Hall, Theresa Schwartz, Nadia Jaber, Jessica Weakley , Thomas E Rohan, Hillel W Cohen, Olga Derman, Thomas K Aldrich, Kerry Kelly, David J Prezant. Lancet September 3, 2011, Vol. 378, No. 9794, pp. 898–905.
  
  This study examined cancer incidence and its potential association with exposure in the first 7 years after 9/11in firefighters with health information before 9/11 and minimal loss to follow-up. 9853 men who were employed as firefighters on Jan 1, 1996 were assessed. On and after 9/11, person-time for 8927 firefighters was classified as WTC-exposed; all person-time before 9/11, and person-time after 9/11 for 926 non- WTC-exposed firefighters, was classified as non-WTC exposed. The ratio of incidence rates were estimated in WTC-exposed firefighters to non-exposed firefighters, adjusted for age, race and ethnic origin, and secular trends, with the US National Cancer Institute Surveillance Epidemiology and End Results (SEER) reference population. Compared with the general male population in the USA with a similar demographic mix, the standardized incidence ratios (SIRs) of the cancer incidence in WTC-exposed firefighters was 1.10 (95% CI0.98–1.25). When compared with non-exposed firefighters, the SIR of cancer incidence in WTC-exposed firefighters was 1.19 (95% CI 0.96–1.47) corrected for possible surveillance bias and 1.32 (1.07–1.62) without correction for surveillance bias. Secondary analyses showed similar effect sizes. We reported a modest excess of cancer cases in the WTC-exposed cohort. We remain cautious in our interpretation of this finding because the time since 9/11is short for cancer outcomes, and the reported excess of cancers is not limited to specific organ types. As in any observational study, we cannot rule out the possibility that effects in the exposed group might be due to unidentified confounders. Continued follow-up will be important and should include cancer screening and prevention strategies.